Immunohistochemistry For Cytomegalovirus Research Articles

P261 Co-infection of Clostridioides Difficile Aggravates Poor Outcomes in Inflammatory Bowel Disease with Cytomegalovirus Colitis

Abstract Background Inflammatory bowel disease (IBD) prognosis is adversely affected by both Cytomegalovirus (CMV) colitis and Clostridioides Difficile (CD) infection. This is the first study in Asia to investigate the clinical impact and risk factors associated with their co-infection in IBD patients. Methods We conducted a retrospective cohort study at Linkou Chang Gung Memorial Hospital from January 2000 to May 2021, involving 53 IBD patients diagnosed with CMV colitis through colonic CMV immunohistochemistry staining. Based on stool toxin A/B tests, patients were divided into two groups: CMV only and CMV+CD co-infection. We compared baseline characteristics, clinical manifestations, risk factors, and outcomes between these groups. Logistic regression was used to analyze independent risk factors, and Kaplan-Meier methods evaluated cumulative incidence of remission rates. Results The study included 53 patients (37 in the CMV group and 16 in the Co-infection group). Diarrhea (93.8%) and abdominal pain (87.5%) were more prevalent in the co-infection group. Compared to the CMV group, the co-infection group had higher hospitalization times (2.5 vs. 1, p=0.005), more frequent CMV recurrences (1 vs. 0, p<0.001), and longer durations to achieve clinical (5 vs. 1 months, p<0.001), steroid-free (10 vs. 4 months, p=0.001), endoscopic (17.5 vs. 8.3 months, p=0.011), and histological remission (18 vs. 11 months, p=0.021) (Table 1-1). Kaplan-Meier analysis also indicated similar trends in Figure 1. The use of biologics was identified as an independent risk factor for co-infection (Odds Ratio 13.33, Confidence Interval 1.52-117.15, P=0.02) (Table 1-2). Conclusion Co-infection with CMV and CD in IBD patients leads to significantly worse outcomes. Early identification and aggressive treatment of co-infection in high-risk patients are vital for improving their prognosis.

Medical Imagery: Cytomegalovirus sialadenitis in a patient with B-cell acute lymphoblastic leukemia

Cytomegalovirus (CMV) can cause a broad range of diseases, with severity depending on immune status, comorbidities, and age. Initial CMV infection usually occurs in childhood and is typically asymptomatic, leading to lifelong latency. In immunocompromised patients, CMV can affect multiple organs, but salivary gland infections are rare. This study presents a case of a 66-year-old woman with B-cell acute lymphoblastic leukemia who developed swelling and pain in the right preauricular region during pre-transplant consolidation therapy. Despite a recent bone marrow biopsy indicating morphological remission and a flow cytometry analysis detecting only 0.04 % B lymphoblasts, she exhibited these symptoms. A CT scan revealed enlargement, hyperdensity, and enhancement of the right parotid glands, with accompanying subcutaneous edema. A biopsy of the right parotid gland showed a dense interstitial lymphoplasmacytic infiltrate with numerous Cowdry bodies and smaller granular cytoplasmic inclusions, all testing positive for CMV immunohistochemistry. The findings confirm the diagnosis of CMV sialadenitis in an immunocompromised patient. This case underscores the importance of considering CMV infections in similar clinical scenarios, particularly in patients with compromised immune systems.

Apoptosis, Crypt Dropout, and Equivocal Immunohistochemical Staining May Indicate Cytomegalovirus Infection in Inflammatory Bowel Disease Patients.

Cytomegalovirus (CMV) colitis superimposed on inflammatory bowel disease (IBD) can be challenging to diagnose. This study aimed to determine what histologic clues and immunohistochemistry (IHC) utilization practices, if any, can help diagnose CMV superinfection in IBD. Colon biopsies were reviewed from all patients with CMV colitis with and without IBD between 2010 and 2021 at one institution, along with a separate cohort of IBD patients with negative CMV IHC. Biopsies were assessed for histologic features of activity and chronicity, phlebitis, fibrin thrombi, basal crypt apoptosis, CMV viral cytopathic effect (VCE), and CMV IHC positivity. Features between groups were compared, with statistical significance set at P -value <0.05. The study included 251 biopsies from 143 cases (21 CMV-only, 44 CMV+IBD, 78 IBD-only). Compared with the IBD-only group, the CMV+IBD group was more likely to show apoptotic bodies (83% vs. 64%, P =0.035) and crypt dropout (75% vs. 55%, P =0.045). CMV was detected by IHC in 18 CMV+IBD cases without VCE on hematoxylin and eosin (41%). In the 23 CMV+IBD cases where IHC was performed on all concurrent biopsies, IHC was positive in at least 1 biopsy in 22 cases. Six individual CMV+IBD biopsies with no VCE on hematoxylin and eosin demonstrated equivocal IHC staining. Of these, 5 had evidence of CMV infection. IBD patients with superimposed CMV infection are more likely to demonstrate apoptotic bodies and crypt dropout compared with their noninfected counterparts. Equivocal IHC staining for CMV may indicate true infection in IBD patients, and staining multiple biopsies from the same accession can improve CMV detection.

S3354 Ménétrier’s Disease: A Rare Cause of Edema in Childhood

Introduction: Ménétrier’s disease (MD) is a rare protein-losing gastropathy characterized by enlarged gastric rugal folds. Adult MD is associated with a high degree of morbidity and mortality due to potential malignant transformation and need for gastrectomy. Pediatric MD, in contrast, is typically an acute, self-limited process, frequently associated with cytomegalovirus (CMV) infection of the stomach. Case Description/Methods: A previously healthy 2-year-old boy was admitted for generalized edema, which had been preceded by a week of diarrhea. Growth and development had been normal. Initial laboratory evaluation was notable for serum albumin of 1.3 g/dL. Other labs were largely unremarkable. Cardiac, renal, and liver etiologies were excluded. Esophagogastroduodenoscopy showed a normal gastric antrum, but the remainder of the stomach had enlarged rugae with areas of ulceration and nodularity. The duodenum and esophagus appeared normal. Histology was notable for hyperplastic gastric pits and foveolae. Immunohistochemistry for CMV and Helicobacter pylori were negative, and viral culture of a gastric sample was also negative for CMV. CMV serologies showed elevated IgM and IgG levels. Additionally, a viral enteric pathogens panel was positive for sapovirus. The patient received 2 doses of albumin and antisecretory agents during admission, but his edema and hypoalbuminemia improved without treatment of CMV. Discussion: In a toddler presenting with edema and hypoalbuminemia, it is necessary to consider protein-losing gastroenteropathies on the differential. Endoscopic evaluation with biopsy is essential for diagnosis of MD. Histology may show foveolar hyperplasia with cystic dilation of pits of the gastric body with relative sparing of the gastric antrum. Full-thickness biopsy may be required to detect classic histologic findings. Evaluation for infection should be done as one-third of pediatric cases are associated with CMV. Management of pediatric MD is primarily supportive due to the self-limited nature of the condition. Treatment with ganciclovir can be considered for severe or refractory cases associated with CMV.

Current Status of Opportunistic Infection in Inflammatory Bowel Disease Patients in Asia: A Questionnaire-Based Multicenter Study.

Background/AimsOpportunistic infection in inflammatory bowel disease (IBD) has become a serious problem. However, its status of doctors’ opinions and test equipment in hospitals are unclear. The aim of the study was to investigate these issues to improve the prognosis of IBD patients.MethodsThis retrospective, multicenter study was conducted by 83 investigators who were members of the Asian Organization for Crohn’s and Colitis. Data on opportunistic infection were collected from hospital databases between January 2017 and December 2017. The survey consisted of 11 items.ResultsMost physicians appreciated the diagnostic value of tissue cytomegalovirus (CMV) DNA, accounting for 86.1% of members in China, 37.5% in Japan, 52.9% in South Korea, and 66.7% in Southeast Asia. Only 83.1% of hospitals had the ability to test for CMV immunohistochemistry in Asia. Hepatitis B surface antigen (HBsAg) screening was recommended by all members. However, only 66.7% in China, 70.6% in South Korea, and 66.7% in Southeast Asia agreed to routinely vaccinate IBD patients when HBsAg tested negative. Most members preferred metronidazole (74.7%) as the first choice for patients with Clostridium difficile infection. However, the proportion of stool C. difficile toxin test was lower in China than in other areas (75.0% in China vs 95.8% in Japan and 100% in South Korea and Southeast Asia, p<0.05).ConclusionsOpportunistic infection from CMV, hepatitis B virus, and C. difficile should be of high concern for IBD patients. More efforts are needed, such as understanding consensus in clinical practice and improving testing facilities in hospitals.

Risk Factors, Clinical and Endoscopic Features, and Clinical Outcomes in Patients with Cytomegalovirus Esophagitis.

Cytomegalovirus (CMV) esophagitis is the second most common CMV disease of the gastrointestinal tract. This study aims to comprehensively analyze risk factors, clinical characteristics, endoscopic features, outcomes, and prognostic factors of CMV esophagitis. We retrospectively collected data of patients who underwent esophageal CMV immunohistochemistry (IHC) staining between January 2003 and April 2021 from the pathology database at the Chang Gung Memorial Hospital. Patients were divided into the CMV and non-CMV groups according to the IHC staining results. We enrolled 148 patients (44 CMV and 104 non-CMV patients). The risk factors for CMV esophagitis were male sex, immunocompromised status, and critical illness. The major clinical presentations of CMV esophagitis included epigastric pain (40.9%), fever (36.4%), odynophagia (31.8%), dysphagia (29.5%), and gastrointestinal bleeding (29.5%). Multiple diffuse variable esophageal ulcers were the most common endoscopic feature. The CMV group had a significantly higher in-hospital mortality rate (18.2% vs. 0%; p < 0.001), higher overall mortality rate (52.3% vs. 14.4%; p < 0.001), and longer admission duration (median, 24 days (interquartile range (IQR), 11–47 days) vs. 14 days (IQR, 7–24 days); p = 0.015) than the non-CMV group. Acute kidney injury (odds ratio (OR), 174.15; 95% confidence interval (CI), 1.27–23,836.21; p = 0.040) and intensive care unit admission (OR, 26.53; 95% CI 1.06–665.08; p = 0.046) were predictors of in-hospital mortality. In conclusion, the mortality rate of patients with CMV esophagitis was high. Physicians should be aware of the clinical and endoscopic characteristics of CMV esophagitis in high-risk patients for early diagnosis and treatment.

Cytomegalovirus Diseases of the Gastrointestinal Tract.

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract can be fatal. However, very few studies have provided comprehensive analyses and specified the differences in symptoms observed in different parts of the GI tract. This study aimed to comprehensively analyze clinical manifestations and management of GI CMV disease. This retrospective cohort study enrolled the patients who had CMV diseases of the GI tract proved by CMV immunohistochemistry stain from the pathology database in a 4000-bed tertiary medical center between January 2000 and May 2021. The patient characteristics, clinical manifestations, endoscopic features, treatments, outcomes, and prognostic factors were analyzed. A total of 356 patients were enrolled, including 46 infected in the esophagus, 76 in the stomach, 30 in the small intestine, and 204 in the colon. In total, 49.4% patients were immunocompromised. The overall in-hospital mortality rate was 20.8%: CMV enteritis had the highest rate (23.3%). Sixty percent of patients received antiviral treatment and 16% were administered both intravenous and oral anti-viral drugs (Combo therapy, minimal and mean treatment duration were 14 and 39.9 ± 25 days). Prognostic factors of in-hospital mortality included age, immune status, albumin level, platelet count, GI bleeding, time-to-diagnosis, and Combo therapy. In the survival analysis, immunocompetent patients receiving Combo therapy had the best survival curve, and immunocompromised patients receiving non-Combo therapy had the worst survival curve. Combo therapy ≥14 days resulted in a better outcome for both immunocompromised and immunocompetent patients. In conclusion, CMV GI diseases affect both immunocompromised and immunocompetent hosts, and a complete treatment course should be considered for patients with poor prognostic factors.

The Trends of Immunohistochemistry for Tissue-Invasive Cytomegalovirus in Gastrointestinal Mucosal Biopsies.

Cytomegalovirus (CMV) immunohistochemistry (IHC) is the most widely used method to diagnose CMV infection/reactivation in tissues in a pathology laboratory. To improve the efficiency of CMV IHC testing by evaluating immunopositive staining trends of tissue-invasive CMV in the gastrointestinal system. A total of 1479 individual orders for CMV IHC on gastrointestinal biopsy specimens from 2016 to 2018 were included. The analysis was performed to identify the significant factors contributory to CMV-positive test results. The overall positivity rate of CMV IHC in our institution was 4.73% (70 of 1479). The positivity rate from physician-requested and pathologist-initiated tests was significantly different (7.54% versus 3.83%, P = .004). Cases with severe inflammation showed a higher positive CMV rate than those with mild inflammation (5.37% versus 2.60%, P = .04). Cytomegalovirus positivity in biopsies from posttransplant patients, inflammatory bowel disease, human immunodeficiency virus (HIV)/common variable immunodeficiency (CVID), cancer, and others was 19.69%, 3.84%, 23.33%, 9.00%, and 2.84%, respectively. The positivity rate among posttransplant, HIV/CVID, or cancer patients was significantly higher than in other populations. Cases tested with multiple tissue blocks generated a higher positivity rate than those with a single block (7.77% versus 3.23%, P < .001). Testing 3 to 4 blocks per case almost tripled the positive CMV detection rate (9.04%). Interestingly, using 5 or more blocks did not further ameliorate the positive CMV detection rate. The data revealed that physician request, immunosuppression, multiple blocks, and severe inflammation were strongly related to positive CMV IHC detection rate. These findings might provide value in helping pathologists manage CMV IHC testing more efficiently.

Multiple colon ulcers in a patient with HIV: Do not forget amoebiasis

A 66-year-old man with no past medical history presented with 2 weeks of fever, abdominal pain and watery diarrhoea. He tested positive for human immunodeficiency virus (HIV), and the CD4+ T-cell count was 43.8/mL. Endoscopy revealed multiple circumferential ulcers in the ascending colon (Figure 1), transverse colon and caecum. Biopsies from the colonic ulcers showed numerous amoebic trophozoites (Figure 2, arrows) and eosinophilic intranuclear inclusion bodies (Figure 2, arrowheads). Immunohistochemistry for cytomegalovirus (CMV) (Dako mouse anti-CMV monoclonal antibody clone CCH2 + DDG9) was positive in the eosinophilic intranuclear bodies (Figure 3).

A stool test in patients with active ulcerative colitis helps exclude cytomegalovirus disease

Objectives: In severe ulcerative colitis (UC) bowel biopsy is recommended to detect the cytomegalovirus (CMV) infection capable of complicating the course of the disease. Histopathology with immunohistochemistry (IHC) is time-consuming, and a blood polymerase chain reaction (PCR) for CMV DNA is used as an alternative, notwithstanding nothing more than a moderate correlation between the two. We aimed to detect CMV DNA in the stools of patients with active UC, and to compare the results with CMV IHC in bowel biopsies.Materials and methods: Measurement of CMV DNA in stools (copies/ml) entailed PCR, while biopsies assessed inflammation activity (Geboes scale), as well as counts of numbers of CMV IHC-positive cells/biopsy. The severity of UC was assessed using the Mayo score, stool calprotectin and concentrations of C-reactive protein in the blood.Results: 89 of the above pairs of tests for CMV were performed among 75 patients. CMV was detected in 36/89 stool specimens and 19/89 bowel biopsies. The sensitivity of the stool-CMV PCR was thus 84.7%, while specificity was of 71.4%. The negative predictive value was 94.3% and the positive predictive value 44.4%. No difference in the severity of UC was noted between the stool CMV DNA positive and negative groups. Similarly, there was no difference in the severity of UC between the CMV IHC positive and negative groups, except for the Geboes score, more often found to be higher in CMV IHC-positive patients (p = .002).Conclusions: CMV DNA was detected in the stools of 40.4% of patients with active UC. A negative test result may help to exclude bowel CMV disease.

Pathophysiology of Hyperechogenic Bowel in Congenitally Human Cytomegalovirus Infected Fetuses.

Hyperechogenic bowel (HB) is a nonspecific ultrasound finding that can be associated with human cytomegalovirus (CMV) congenital infection. In this study, we investigated HB pathophysiology in CMV-infected fetuses. We examined small and large intestine as well as pancreas in 8 fetuses at 22 weeks of gestation with congenital CMV infection. Ultrasound findings showed 4 fetuses with HB and 4 without. As negative group, 4 fetuses without CMV infection and without HB were studied. Immunohistochemistry for CMV, lymphocytic infiltrate, B-cell leukemia/lymphoma-2 (bcl-2), CD-117, cystic fibrosis transmembrane regulator (CFTR) were performed. HB fetuses showed multiple and sequential CMV-positive ganglion cells of Auerbach’s myenteric plexus. In the ganglia, bcl-2 was weakly expressed representing a reduced neuronal functionality. CD-117 revealed a regular distribution of Cajal cells, the pacemakers of intestinal contractility. Pancreas showed normal CFTR staining, indicating a preserved exocrine secretion, thus unlikely a contributory factor in HB. In CMV-infected fetuses without HB, CMV-positive cells were scatteredly found in ganglion cells and bcl-2 was strongly expressed. Intestinal CD-117 and pancreatic CFTR expression were similar to fetuses with HB. In conclusion, fetal CMV infection of the bowel may lead to peristalsis impairment (paralytic ileus) due to intestinal plexus involvement, which at ultrasound appeared as HB.

2318 A Rare Case of Cytomegalovirus Hepatitis Complicated by Secondary Syphilis Hepatitis in an Immunocompetent Patient

INTRODUCTION: Cytomegalovirus (CMV) hepatitis most commonly presents with subclinical transaminitis and less commonly with the elevation of alkaline phosphatase (ALP) and total bilirubin (TB). Syphilis hepatitis, on the other hand, generally has a non-specific presentation with a more cholestatic picture. We present a rare case of cholestatic hepatitis from acute CMV infection complicated by syphilis hepatitis. CASE DESCRIPTION/METHODS: A 57-year-old homosexual man presented to the emergency room with complaints of intermittent fever and general malaise for the past two weeks. Blood work showed aspartate aminotransferase (AST) of 235 U/L, alanine aminotransferase (ALT) of 284 U/L, ALP of 940 U/L. TB and coagulation profile were normal. Acute hepatitis A, B, C, Epstein-Barr virus, and herpes simplex virus were ruled out. HIV was negative. Workup for autoimmune hepatitis, primary biliary cholangitis, alpha-1-antitrypsin deficiency, and Wilson’s disease was all negative. Abdominal CT scan with contrast was notable for hepatosplenomegaly without liver lesion. CMV IgM was positive with PCR of 7490 copies/mL, indicating acute CMV infection. The patient subsequently improved without treatment. He presented two months later with worsening liver tests with a peaked ALP of 1981 U/L, TB of 1.6 mg/dL, AST 230 U/L, ALT 195 U/L, associated with the macular rash on his trunk, abdomen, both palms, and soles. Abdominal MRI with contrast showed three &lt; 2cm liver lesions. The patient was subsequently diagnosed with secondary syphilis with rapid plasma reagin (RPR) of 1:16 and confirmatory positive fluorescent treponemal antibody absorption (FTA-ABS). Biopsy of the liver lesions showed granulomatous inflammation with negative immunohistochemistry for CMV which was compatible with clinical syphilis hepatitis. The patient was treated with penicillin G. His rash resolved in 2 months with significant improvement of liver tests. The CMV PCR and RPR were negative with normalization of liver enzymes in 4 months. Follow-up MRI showed resolution of the liver lesions. DISCUSSION: Our patient initially had an atypical presentation of acute CMV hepatitis with cholestatic features. He subsequently developed secondary syphilis associated hepatitis with severe intrahepatic cholestasis and liver lesions. This is, to our knowledge, the first case of CMV hepatitis complicated by syphilis hepatitis. Resolving CMV hepatitis with recurrent elevation in liver tests warrant the workup for possible superimposed liver disease.

P028 High cytomegalovirus DNA load in mucosal biopsies predicts steroid failure as well as colectomy in acute severe ulcerative colitis

BACKGROUND: Cytomegalovirus (CMV) reactivation may be responsible for steroid refractory acute severe colitis (ASC), which requires rescue therapy in form of surgery or advanced immunosuppression. The optimum technique for diagnosing CMV colitis in this setting remains unclear. We investigated the role of CMV Quantitative PCR for diagnosing CMV colitis and for predicting of steroid-failure in ASC. METHODS: Consecutive patients with ASC satisfying Truelove and Witts' criteria, hospitalized at a single centre from May 2016 to November 2017, were included. The primary outcome measure was steroid-failure defined as colectomy and/or rescue therapy with ciclosporin or infliximab during admission. Oxford criteria, ulcerative colitis index of severity (UCEIS) at day 1 and fecal calprotectin (FCP) at day 3 were used to predict steroid response. Immunohistochemistry (IHC) and quantitative PCR for CMV was done on mucosal biopsies and the results were compared between steroid responders and non-responders. RESULTS: Of 37 patients (Mean age: 35 ± 12 years, 70% males), 14 (38%) failed iv corticosteroids and 8 (25%) required surgery. Although IHC for CMV was not different between steroid failures and responders (29% vs 17%, P = 0.40), patients with steroid failure had a significantly higher median level of mucosal CMV DNA (7,840 [0–2,700,000] vs 112 [0–34,459] copies/mg, P = 0.03). Significantly greater number of patients with steroid failure had CMV DNA count &gt;1,000 copies/mg (71% vs 26%, P = 0.007). CMV DNA count &gt;1,000 copies/mg (odds ratio 6.5 [95% confidence interval 1.3–33, P = 0.03]) and positive oxford criterion on day 3 of iv corticosteroids (OR 6 [95% CI 1.2–30, P = 0.03]) were independent predictors of steroid-failure and need for rescue therapy/colectomy. CONCLUSION(S): CMV DNA quantification in mucosal biopsy can detect CMV colitis and predict steroid failure in acute severe colitis with reasonable accuracy.

Placental Cytomegalovirus Infection.

In the United States, cytomegalovirus is the most common congenital viral infection and the number 1 cause of nonhereditary sensorineural hearing loss. The vast majority of infants may be asymptomatic, especially if cytomegalovirus is contracted later in the pregnancy, and some symptoms may have a delayed onset. Therefore, it is important for the pathologist to identify the common histologic findings to help confirm the diagnosis so the child can be followed for late sequelae. Histologic examination of the placenta is important in live births and in cases of intrauterine fetal demise. Chronic lymphoplasmacytic villitis and fibrotic, avascular villi are the most common findings. When present, Cowdry A intranuclear and basophilic intracytoplasmic inclusions are characteristic. Immunohistochemistry for cytomegalovirus can highlight these inclusions as well as the associated eosinophilic debris. In addition, polymerase chain reaction or viral culture on placental or fetal samples can be performed for confirmation.

Assessment of Disease Severity and Role of Cytomegalo Virus Infection in Patients with Ulcerative Colitis.

Course of Ulcerative Colitis is characterized by intermittent flares interposed between variable periods of remission. Identification of exacerbating factors and appropriate assessment of disease activity are crucial in deciding the choice of treatment. To evaluate various clinical, endoscopic and histological parameters in assessing disease activity and to find out various risk factors involved in the exacerbation of ulcerative colitis especially the role of Cytomegalo Virus (CMV) infection. It was a prospective study of patients diagnosed as ulcerative colitis presenting with acute exacerbation of symptoms (cases) and those who were in remission (controls). A detailed evaluation of the disease history including personal history, treatment compliance and clinical disease severity were noted. Investigations including blood routine, endoscopic examination with biopsy, histopathological examination and immunohistochemistry for CMV were done on the biopsy sample. A total of 58 patients with ulcerative colitis were studied which included 37 cases and 21 controls. Out of the various clinical and demographic parameters, Good treatment compliance (p =0.0003) and Perceived Stress Scale (PSS) score (p=0.0001) showed significant difference between cases and controls. Basic laboratory parameters {Haemoglobin level, Total Leucocyte Count (TLC) and Erythrocyte Sedimentation Rate (ESR)}, clinical disease severity predictors (Truelove and Witt's criteria, Mayo score and endoscopic disease severity grade) and Geboes histological scoring showed significant difference between cases and controls. The prevalence of CMV colitis in our study was only 5.4% (two cases). Clinical and endoscopic disease severity indicators can be used as predictors of histological activity in ulcerative colitis. Poor treatment compliance and stress are important risk factors for acute exacerbation of ulcerative colitis. Clinicians should be aware of the possibility of concurrent CMV infection while treating patients with acute exacerbation of ulcerative colitis not responding to the conventional management. Reduced prevalence of CMV colitis in cases of acute exacerbation of ulcerative colitis in our study may be due to the small sample size, reduced number of steroid dependent cases or reduced severity of our cases.

Pathology Results of Tissue Biopsy during Idelalisib-Associated Diarrhea/Colitis

Introduction: Idelalisib (IDELA) is a targeted PI3Kd inhibitor approved for the treatment of patients (pts) with relapsed CLL/FL. The established toxicity profile of IDELA includes diarrhea/colitis with a grade ≥3 incidence of ~15%. Here, we present the histopathological-as well as immune profiling and viral testing-results of gastrointestinal tissue specimens from pts who received diagnostic biopsies for abdominal pain or diarrhea during treatment with IDELA.Methods: Intestinal biopsy specimens obtained from 31 pts during treatment with IDELA across 10 trials (monotherapy n = 3 or in combination with: rituximab n = 9; ofatumumab n = 14; and bendamustine/rituximab n = 5) were reviewed separately by 2 independent pathologists with expertise in the area of gastrointestinal and transplant pathology. If more than 1 biopsy time point per pt was available (n = 3), all time points would be evaluated and, if discordant, would be reported separately. Evaluation included hematoxylin and eosin stain; and immunohistochemistry (IHC) for CD3, CD8, FOXP3, CD79a, CMV, and adenovirus (as adequate tissue allowed). Additionally, droplet digital PCR (ddPCR) was performed for cytomegalovirus (CMV), adenovirus, and human herpesvirus 6 (HHV-6). Colon/small bowel tissues from 18 normal individuals who underwent biopsy during routine screening colonoscopy and had normal pathology results were included as controls.Results: Baseline characteristics of pts included CLL n = 24 (77.4%) and iNHL n = 7 (22.6%), age range 50 to 82 years with median 65.6 years, male n = 19 (61.3%). IDELA median dose = 150 mg BID. Diarrhea/colitis (Grade 1-3) was reported in 24 cases (75%) including 1 case of hemorrhagic colitis. One patient each had concurrent laboratory-confirmed Mycobacterium avium-intracellulare and norovirus and 2 patients were excluded from histomorphological analysis, 1 due to celiac disease and 1 due to total loss of glands secondary to CMV. Four distinct morphological patterns were identified: 1) predominantly normal, 2) apoptotic, 3) inflammatory/ischemic, and 4) mixed apoptotic/inflammatory/ischemic. CMV IHC was performed in all 31 cases; 2 showed strong/moderate positivity, and 2 were weakly positive. Adenovirus IHC was performed on 29 specimens, and 1 was weakly positive. ddPCR performed on 27 formalin-fixed paraffin-embedded tissues identified 6 positive CMV cases (including all 4 IHC+ cases), 0 adenovirus cases, and 1 HHV-6-positive case. Among the CMV cases, the most common pattern was mixed, seen in 4 of 6 cases, whereas the most common morphologic feature was apoptosis, seen in 5 of 6 cases. A summary of findings is shown in Table 1.Conclusion: In this subset of pts who underwent intestinal biopsy during IDELA clinical trials, most biopsies (87%) were performed in the context of ongoing diarrhea/colitis and the majority of tissue samples (90%) revealed some component of inflammation. Immune profiling by IHC showed increased Tregs in patterns associated with glandular destruction. Immunohistochemistry and ddPCR for virus in conjunction with microbiology studies revealed that in 28% of these cases, a pathogen was identified. This dataset suggests that in a significant number of cases, idelalisib-associated diarrhea/colitis may be due to an infectious etiology secondary to immune dysfunction that results in either an inflammatory/ischemic or a mixed histologic pattern; however, the majority of these cases have no identifiable infectious etiology. Based on these findings, we recommend that a workup of pts with idelalisib-associated diarrhea/colitis should include a complete evaluation for infectious causes including intestinal biopsy when a pathogen is elusive with standard testing. [Display omitted] DisclosuresYeung:Gilead Sciences: Research Funding. Hockenbery:Gilead Sciences: Research Funding. Coutre:Gilead Sciences: Consultancy, Research Funding. Dubowy:Gilead Sciences: Employment, Equity Ownership. Marcondes:Gilead Sciences: Employment, Equity Ownership. Munugalavadla:Gilead Sciences: Employment, Equity Ownership. Bosch:Gilead Sciences: Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Honoraria, Research Funding.

Cytomegalovirus disease in inflammatory bowel disease: epidemiology and disease characteristics in a large single-centre experience.

Patients with inflammatory bowel disease (IBD) show an increased risk of developing cytomegalovirus (CMV) disease because of immunosuppressive medication and malnutrition. Here, we aimed to investigate the prevalence and clinical characteristics of CMV disease in our cohort of IBD patients. We carried out a retrospective analysis of 1023 IBD patients treated at our IBD clinic at the University Hospital Zurich between 2007 and 2014. CMV disease was defined as a positive immunohistochemistry for CMV and 14 patients were identified. The prevalence of CMV disease in our IBD cohort was 1.37%. Twelve patients had ulcerative colitis and two had Crohn's disease with colonic involvement. All patients who developed CMV disease received immunosuppressive medication or, as in one case, had HIV infection. The most used immunosuppressive medications were steroids and azathioprine. The most common therapeutic strategy was the consecutive use of ganciclovir and valganciclovir. Ten patients recovered and two were treatment refractory; among these, one required colectomy and two had a relapse. CMV disease may influence the clinical course of IBD. There is probably an association between CMV disease and IBD-specific medication. Risk factors, epidemiology and therapeutic strategy need to be further investigated.

Chronic Granulomatous Disease Mimicking Colonic Crohnʼs Disease Successfully Treated with Infliximab

We present a case of a 41-year-old female patient with chronic diarrhea for 3 years associated with a significant weight loss, without any other gastrointestinal symptoms. Stool analysis were negative. Celiac and Whipple's diseases were excluded. An ileocolonoscopy was performed and showed multiple well-defined rectal ulcers. Biopsies were carried out and revealed some epithelioid granulomas with giant cells. Immunohistochemistry for cytomegalovirus, periodic acid-Schiff and Ziehl-Neelsen stains were negative. After reviewing the past medical history of the patient it was found that one of her children had died at the age of 9-years-old with a septic complication due to a chronic granulomatous disease (CGD). A cellular immunity and oxidative burst of granulocytes study was performed and showed a shortfall in the production of oxidative metabolites in 35% of granulocytes, therefore establishing the diagnosis of CGD carrier linked to chromosome X. Considering the increase risk of bacterial and fungal infections of these patients, an endoscopic re-evaluation was performed and a Nocardia infection located in one of the rectal ulcers was diagnosed throughout a polymerase chain reaction (PCR), and she started cotrimoxazole for 3 months followed by continuous weekly prophylaxis. 42 days after colonic biopsies were performed, a positive cultural result for mycobacteria tuberculosis was depicted. Anti-tuberculosis therapy was started for 12 months. After finishing the intestinal tuberculosis treatment, in an endoscopic evaluation, the histological evaluation showed that the epithelioid granulomas remained. Also, herpes simplex virus 1 and Aspergillus fumigatus were isolated throughout PCR method. After controlling these infections, and as she maintenance complains of diarrhea (more than 10 bowel movements per day), with further weight loss. When treatment options were discussed with the patient, she proved to be reluctant to initiate corticosteroids to control the inflammatory manifestations for fear of steroid-related adverse effects. As such, it was decided, in a multidisciplinary meeting, to start therapy with infliximab at a 5 mg/kg dose. Currently, after 15 months of therapy, the patient showed a significant improvement of symptoms, a reduction in the number of stools and recovery of body weight (3 per day). During this period the patient did not have any infectious complications.Figure 1

Cytomegalovirus (CMV) in gastrointestinal mucosal biopsies: should a pathologist perform CMV immunohistochemistry if the clinician requests it?

Cytomegalovirus (CMV) causes clinically significant gastrointestinal (GI) injury. CMV inclusions can be identified on routine hematoxylin and eosin (H&E) stain, but immunohistochemistry (IHC) is also available for identifying CMV in tissue. The advent of accountable care organization models of care bring into question whether it is cost-effective for immunohistochemistry to be performed upfront at the request of clinicians and whether the quality of viral detection is compromised when the diagnosis of CMV is predicated on histologic review. In this study, a retrospective review of GI biopsies with CMV evaluations was performed. There were 449 cases with clinical requests to rule out CMV and 238 CMV analyses initiated by the pathologist without a clinical request. Among the cases that included a clinician's request, 37 had CMV detected. Immunostaining was performed on 26 cases, while a diagnosis based on readily identifiable viral inclusions on H&E-stained slides was made in 11. Among pathologist-initiated work-ups, 15 were CMV+, 3 of which had inclusions identified by H&E only. Among 38 CMV cases for which IHC had been performed, 27 had overt viral inclusions obvious on H&E. Seventy-two cases revealed uninflamed GI mucosa, and although a clinical concern about CMV infection was present, a CMV IHC work-up was not initially performed; all were negative for CMV by IHC and H&E. Clinical suspicion for CMV has a high yield for CMV detection, but "upfront" testing is likely unnecessary. Careful histopathologic review by a pathologist remains critical in the efficient and cost-effective detection of CMV.

Histological features of Cytomegalovirus-related corneal graft infections, its associated features and clinical significance

AimTo describe the histological features of Cytomegalovirus (CMV)-related corneal graft infections, its associated features and clinical significance.MethodsThis was a retrospective histological study of 48 consecutive cases of failed repeat penetrating...